cervical artery presentation
DESCRIPTION
Presentation discussing research and pathophysiology behind the proposed association between cervical thrust manipulation as performed by physical therapists, chiropractors, osteopaths, and medical physicians and cervical artery dissection and subsequent strokeTRANSCRIPT
Cervical Artery DysfunctionCervical Artery Dysfunctionand Manipulation: A Causeand Manipulation: A Cause--
andand--Effect Relationship?Effect Relationship?
Orthopaedic Speaker Series
Royal Jubilee Hospital
Victoria, BC
April 14th, 2009
Dr. Peter Huijbregts, PT, DPT
ObjectivesObjectives
Discuss epidemiology of cervical (vertebrobasilarand internal carotid) artery dysfunction
Discuss anatomy and physiology relevant tocervical arterial dysfunction
Discuss research linking cervical manipulation toartery dysfunction
Discuss relevant clinical (differential) diagnosisDiscuss risk management and emergencyprocedures with regard to cervical arterydysfunction
Note: absence of risk-benefit discussion
Timely?Timely?
Mrs. Sandy Nette, Edmonton, AB
Bilateral vertebral artery dissection
Chiropractic neck manipulation
$ 500-million class-action lawsuit againstchiropractor, his clinic, Alberta College andAssociation of Chiropractors, and AB Ministry ofHealth and Wellness
Benedetti P, McPhail W. Twist and Shout. Globe and Mail, June 14, 2008
Clinical Vignette # 1Clinical Vignette # 1
20-year old female
Fell down stairs and hurt her back
Boyfriend suggested seeing his chiropractor
Over the next months 189 adjustments in 21visits including upper cervical
Note: initial complaint was low back pain…
Clinical Vignette # 1Clinical Vignette # 1
Rotary neck manipulation resulted ininability to turn head
That night she kept walking into things atwork
Another visit to chiropractor next day
Clinical Vignette # 1Clinical Vignette # 1
Neck adjustment
Patient immediately began to cry
Left eye rolled up, right roamed randomly
Convulsions
Clinical Vignette # 1Clinical Vignette # 1
Turned blue, foaming at the mouth, did notrecognize her mother
Coma
Died next day from a traumatic rupture leftvertebral artery
Relevance to Physiotherapy?Relevance to Physiotherapy?
With research evidence supporting its efficacyphysiotherapists routinely use cervicalmanipulation in patients with:
Neck pain
Headache: Cervicogenic, tension-type, migraine
Dizziness: Cervicogenic
19/20 member organizations IFOMT teach uppercervical manipulation
Rivett D, Carlesso L. Safe Manipulative Practice in the Cervical Spine (2008)
Do these patients make up aDo these patients make up abig portion of our daybig portion of our day--toto--dayday
clinical practice?clinical practice?
In other words:In other words:
What is the risk aWhat is the risk aphysiotherapist mightphysiotherapist might
inadvertently cause a strokeinadvertently cause a strokewith cervical manipulation?with cervical manipulation?
Epidemiology Neck PainEpidemiology Neck Pain
• Point prevalence neck pain: 9%
• 6-month prevalence: 54%
• Lifetime prevalence: 66%
• Point prevalence chronic neck pain (>6 months):18%
Douglass AB, Bope ET. Evaluation and treatment of posterior neck pain in familypractice. J Am Board Fam Pract 2004;17:S13-S22.
Guez M, et al. Chronic neck pain of traumatic and non-traumatic origin. ActaOrthop Scand 2003;74:576-579
Epidemiology HeadacheEpidemiology Headache
Cervicogenic headache: 0.4-2.5% in the generalpopulation and up to 15-20% in those with chronicheadaches
Tension-type headache: Two-thirds of males andover 80% of females in developed countries
Migraine headache: 1-year prevalence 6-8% inmales and 15-18% of females in Europe and US
World Health Organization. Headache Fact Sheet. 2008.
Haldeman S, Dagenais S. Cervicogenic headaches: A critical review. Spine J2001;1:31-46
Epidemiology DizzinessEpidemiology Dizziness
Dizziness accounts for 7% of physician visits forpatients over the age of 45
For adults over 65, it is the number one reason tovisit a physician
Approximately 15 to 30% of people experiencingdizziness will seek medical attention
Huijbregts P, Vidal P. Dizziness in orthopaedic physical therapy practice:Classification and pathophysiology. J Manual Manipulative Ther
2004; 12: 196-211
Relevance to Physiotherapy?Relevance to Physiotherapy?
Cervical spine diagnoses were the reason forreferral in 16% of 1,258 outpatient PT patients,second only to lumbar spine-related diagnoses
Headache reported as co-morbidity in 22% of2,433 patients presenting for outpatient PT/OT
Boissonnault WG. Prevalence of comorbid conditions, surgeries, andmedication use in a physical therapy outpatient population: A multi-centered study. J Orthop Sports Phys Ther 1999;29:506-519
Relevance to PhysiotherapyRelevance to Physiotherapy
Now wait a minute…
Relevance to PhysiotherapyRelevance to Physiotherapy
Now wait a minute…
Why would we as physiotherapists beworried about the association betweenmanipulation and stroke?
Relevance to PhysiotherapyRelevance to Physiotherapy
Now wait a minute…
Why would we as physiotherapists beworried about the association betweenmanipulation and stroke?
Isn’t this purely a chiropractic problem?
Clinical Vignette # 2Clinical Vignette # 2
63-year old male
Hypertensive
Right cerebral infarct five years earlier
Four months previously vertebrobasilarinfarct
Clinical Vignette # 2Clinical Vignette # 2
PHYSIOTHERAPIST applied cervicalmanipulation
Immediate dizziness post-manipulation
Over the next few hours dysarthria,dysphagia, and left-sided paralysis
Medullary infarct
Relevance to Physiotherapy?Relevance to Physiotherapy?
“…The temporal relationship between young healthypatients without osseous or vascular disease whoattend an SMT practitioner and then suffer theserare strokes is so well documented as to be beyondreasonable doubt indicating a possible causalrelationship…”
Terrett AGJ. Vertebrobasilar stroke following spinal manipulation therapy. In:Murphy R. Conservative Management of Cervical Spine Syndromes (2000)
Relevance to Physiotherapy?Relevance to Physiotherapy?
Rare strokes?
Read: Dissection of the vertebral and/orinternal carotid arteries (ICA)
Epidemiology Cervical ArteryEpidemiology Cervical ArteryDissectionDissection
Cervical artery dissection accounts forapproximately 20% of all strokes in young versus2.5% in older patients
Incidence general population: 2.6 per 100,000
Note the low incidence!
Graziano DL, Nitsch W, Huijbregts PA. Positive cervical artery testing in a patientwith chronic whiplash syndrome. J Manual Manipulative Ther 2007;15:E45-E63
Manipulation, Dissection, andManipulation, Dissection, andStroke?Stroke?
Time to review some material?
1. Arterial anatomy
2. Mechanisms of arterial injury
3. Anatomy and physiology of the cervicalarteries
Anatomy: ArteryAnatomy: Artery
Three-layer structureartery
Intima
Media
Adventitia
Anatomy: ArteryAnatomy: Artery
INTIMA
Layer of endothelial cells lining vessel interior
Rests on basal lamina
Turnover rate 1% per day
Sub-endothelial layer: longitudinally arrangedloose connective tissue and some smooth musclecells
In arteries: Internal elastic lamina, fenestratedelastin allows diffusion to vessel wall
Anatomy: ArteryAnatomy: Artery
MEDIA
Concentric layers of helically arrangedsmooth muscle cells
Variable amounts of elastic fibers andlamellae, reticular fibers, and proteoglycans
In larger arteries: External elastic laminaseparating media from adventitia
Anatomy: ArteryAnatomy: Artery
ADVENTITIA
Longitudinally oriented Type I collagen andelastic fibers
Gradually becomes continuous withenveloping connective tissue
Junqueira LC, et al. Basic Histology. 8th ed (1995)
Mechanisms of ArterialMechanisms of ArterialTraumaTrauma
Subintimal hematoma
Intimal tear
Intimal tear with thrombus formation
Intimal tear with embolic formation
Vessel wall dissection with subintimal hematoma
Vessel wall dissection with pseudo-aneurysm
False aneurysm
Subintimal HematomaSubintimal Hematoma
Disruption vasavasorum leads tosubintimal bleedingand occlusion of VAlumen
May also causevasospasm
Intimal TearIntimal Tear
Intima is the least elasticlayer and, therefore, mostlikely to tear
Exposure sub-endotheliallayer causes thrombosis
Clot may propagateproximally or distally
Vasospasm due tothrombin release
Intimal Tear with EmbolizationIntimal Tear with Embolization
Propagating clotextends into lumenand breaks off
Embolus
Distal arterialocclusion andinfarction
Dissection and SubintimalDissection and SubintimalHematomaHematoma
Disruption intima andinternal elastic lamina
Blood dissects these layersfrom muscular media:dissecting aneurysm
Compresses lumen
Exposure sub-endothelialtissue and thrombosis
Dissection and SubintimalDissection and SubintimalHematoma: ReperfusionHematoma: Reperfusion
Hemorrhage mayagain rupture throughintima
Reestablishescommunication withtrue lumen
Recanalization mayoccur
Dissection with PseudoDissection with Pseudo--AneurysmAneurysm
Disruption of media,internal elastic lamina,and intima
Pseudo-aneurysmunder extendingadventitia
May propagate distally
Frequent cause ofocclusion PICA
False AneurysmFalse Aneurysm
Disruption total arterialwall
Peri-arterial hemorrhagecontained in fascia
External compressionlumen
Turbulence in lumen maycause thrombus andembolus formation
Anatomy: Vertebral ArteryAnatomy: Vertebral Artery
V1: ExtraV1: Extra--Vertebral SegmentVertebral Segment
Branches off the subclavian artery and enters thetransverse foramen of C6 in 89% of people
Enters C7 in 3%, C5 in 6%, and C4 in 1% ofpopulation
Anterior boundary formed by anterior scalene andlongus colli muscles
Posterior boundary transverse processes C7-T1and first rib
V2: IntraV2: Intra--Vertebral SegmentVertebral Segment
Runs through transverse foramina C7-C2
Bordered anteromedially by uncovertebraljoints
May be adherent to periosteum of theuncinate processes
Many anatomical variants have beendescribed
V3: AtlantoV3: Atlanto--Axial SegmentAxial Segment
Transverse foramen of C1 is far lateral ascompared to that of C2
This causes a dorsolateral routing of the vertebralartery from the C2 to the C1 transverse foramen
Tethered at C1 and C2 transverse foramina andatlanto-axial membrane
Artery more prone to injury at this segment?
AtlantoAtlanto--Axial Segment andAxial Segment andRotationRotation
V3: AtlantoV3: Atlanto--Axial SegmentAxial Segment
After exiting the C1 transverse foramen the arteryruns medially in a sulcus in the lateral mass of theatlas
Anatomical variant: Arcuate foramen andponticulus posterior in posterior arch atlas
Anterior boundary is formed by the C0-C1 joint
Posterior boundary is formed by the obliquuscapitis superior and rectus capitis posterior majormuscles
V4: Subforaminal and IntraV4: Subforaminal and Intra--CranialCranial SegmentSegment
Pierces the posterior atlanto-occipitalmembrane and dura and arachnoid mater
Courses on intra-cranially in subarachnoidspace
Cervical BranchesCervical Branches
Spinal rami branch off the vertebral arteryand enter the intervertebral foramen wherethey split in anterior and posterior radiculararteries, anterior central artery, and anteriorand posterior vertebral canal arteries
Radicular arteries supply the anterior andposterior nerve roots and spinal ganglion
The other branches supply epidural tissues
Cervical BranchesCervical Branches
Muscular, cutaneous, and articular rami supply thelocal joints, intrinsic cervical muscles, and the skininnervated by the dorsal ramus of the cervicalspinal nerves
These branches also supply the flaval andinterspinal ligaments
The ascending axial arteries supply the body andodontoid process of C2 and the alar, transverse,and cruciform ligaments
SubSub--Foraminal BranchesForaminal Branches
Subforaminal branches include the anterior,posterior, and lateral spinal arteries
The posterior spinal artery also frequentlybranches off from the posterior inferior cerebellarartery
Below C4 these spinal arteries form anastosmoseswith the spinal rami of the vertebral arteriesthrough the anterior radicular arteries
This leaves the upper cervical cord vulnerable tovascular ischaemia: Implication?
IntraIntra--Cranial BranchesCranial Branches
The posterior inferior cerebellar artery (PICA)branches off before coalescence of the vertebralarteries into the basilar artery
PICA supplies the dorsolateral medulla oblongata,the cerebellar vermis, and a number of cerebellarnuclei
The basilar artery supplies the medulla oblongata,the pons, the mesencephalon, and parts of thecerebellum
IntraIntra--Cranial BranchesCranial Branches
The labyrinthine arteries branch off early from thebasilar artery or the anterior inferior cerebellararteries, which makes the vestibular nucleus andthe inner ears very susceptible to ischaemicabnormalities
The posterior cerebral arteries branch off thebasilar artery and supply the thalamus andhypothalamus and the occipital and temporal lobes
Oostendorp R. Functionele Vertebrobasilaire Insufficientie. PhD Thesis.Nijmegen, The Netherlands: Katholieke Universiteit Nijmegen, 1988.
Anatomy: Internal carotidAnatomy: Internal carotidarteryarteryFig 2
C6
C1 (atlas)
Vertebral ArteryInternal Carotid Artery
Anatomy: ICAAnatomy: ICA
Provides 80% of blood flow to the brainversus 20% supplied by the vertebrobasilarsystem
Traverses sternocleidomastoid, longuscapitis, stylohyoid, omohyoid, and digastricmuscles
Anatomy: ICAAnatomy: ICA
Fixed to the anterior aspect of the C1vertebral body and in the carotid canal inthe petrous bone
Sustained rotation and extension-rotationtests have also been proposed as tests ofICA function
Current Emphasis on ICA:Current Emphasis on ICA:Let’s Put This in PerspectiveLet’s Put This in Perspective
Terrett only found five cases (2.7%) of 185reported cervical artery injuries associated
with SMT involving the ICA
Terrett AGJ. Current Concepts: Vertebrobasilar Complications followingSpinal Manipulation (2001)
Serious ManipulationSerious Manipulation--RelatedRelatedAdverse EventsAdverse Events
Two types of vertebral arterystroke:
1. Wallenberg syndrome
2. Locked-in syndrome
Wallenberg SyndromeWallenberg Syndrome
Dorsolateral medullary syndrome ofWallenberg
Occlusion PICA
Other cause: Occlusion parent vertebralartery, a.k.a. syndrome of BabinskiNageotte
Due to destruction nuclei and pathways indorsolateral medulla oblongata
Wallenberg SyndromeWallenberg Syndrome
Inferior cerebellar peduncle: ipsilateral ataxia andhypotonia
Descending spinal tract and nucleus CN V: loss ofpain and temperature sensation ipsilateral face andloss corneal reflex
Ascending lateral spinothalamic tract: loss of painand temperature sensation contralateral trunk andlimbs (alternating analgesia)
Wallenberg SyndromeWallenberg Syndrome
Descending sympathetic tract: IpsilateralHorner’s syndrome
Lower vestibular nuclei: Nystagmus,vertigo, nausea, and vomiting
Nucleus ambiguous of glossopharyngealand vagus nerves: Hoarseness, dysphagia,or intractable hiccups
LockedLocked--In SyndromeIn Syndrome
Cerebromedullospinal disconnectionsyndrome
Occlusion mid-basilar artery
Bilateral ventral pontine infraction
Effectively transects brain stem at mid-ponsregion
Patients are “conscious, paralyzed mutes”
LockedLocked--In SyndromeIn Syndrome
Consciousness retained because reticularformation midbrain and rostral pons isunaffected
Cerebrospinal tracts destroyed: Decerebraterigidity
Nuclei CN V-XII destroyed: Also affectsoculomotor nerve (CN III) due todescending neuronal connections
LockedLocked--In SyndromeIn Syndrome
Cutaneous sensation may be grossly intactbecause lateral spinothalamic tract locatedlaterally in brain stem is spared
Auditory nerves ascend brainstem lateral toinfarct area: Patient still can hear
CN IV spared: Eye convergence andupward gaze intact
BradfordBradford--Hill Criteria forHill Criteria forCausationCausation
Biologically plausible
Proposed cause temporally related tooccurrence
Consistent across different samples andgroups
Positive correlation exposure andoccurrence
No other explanation
BradfordBradford--Hill Criterion # 1:Hill Criterion # 1:Biological PlausibilityBiological Plausibility
It is certainly biologically plausible thatexcessive mechanical force imparted to the
artery could cause arterial wall damage
Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Terrett (1995): Narrative review of English,French, German, Scandinavian, and Asianliterature 1934-2000: 185 cases reported,death in 30 cases
Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Updated in 2001: 236 cases reported
Triano and Kawchuk (2006) updated thisreview and found reports of 80 additionalcases of post-manipulation complications
Triano JJ, Kawchuk G. Current Concepts in SpinalManipulation and Cervical Arterial Incidents (2006)
Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
DiFabio (1999): systematic review overperiod 1925-1997
177 cases with mostly arterial dissection orspasm, brain stem lesion, and Wallenbergsyndrome
Death resulted in 18% (n=32)
Also visual defects, hearing loss, balancedeficits, and phrenic nerve damage
Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Cervical manipulation NOT a new treatment in41% of patients
When described rotational thrust seemed mostinjurious (23%)
However, technique described in only 54%
DiFabio RP. Manipulation of the cervical spine: Risks and benefits. PhysTher 1999;79:50-65
Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Ernst (2002): Systematic review over 1995-2001period
42 cases with serious adverse events: Mainlyarterial dissection
Also long thoracic nerve palsy, disk herniations,myelopathy, epidural hematoma
Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Insufficient data on type of manipulation used
Underreporting bias?
Ernst E. Manipulation of the cervical spine: A systematicreview of case reports of serious adverse events, 1995-2001. Med J Aust 2002;176:376-380
Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
True risk remains unknown
Estimated risks adjusted assuming a reporting rateof only 10% in literature
All complications: 5-10 per 10 million
Serious complications: 6 in 10 million
Risk of death: 3 in 10 million
Hurwitz EL, et al. Manipulation and mobilization of the cervical spine: Asystematic review of the literature. Spine 1996;21:1746-1759
Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
582 cases of vertebrobasilar accidents (VBA) inON, 1993-1998
Age and sex-matched controls from provincialinsurance database
Exposure to chiropractic using provincialinsurance data
VBA< 45 years old 5 times more likely (95% CI1.31-43.87) to have visited a chiropractor within 1week before VBA
Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Also, in younger age group 5 times as likely tohave had ≥ 3 visits with cervical diagnosis inmonth before VBA (95% CI 1.34-18.57)
No significant associations for those over 45 yearsold
Further prospective study indicated; sources ofbias acknowledged
Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation andstroke: A population-based case control study. Stroke 2001;32:1054-
1060
Evidence Linking ManipulationEvidence Linking Manipulationto Stroke?to Stroke?
Population-based study over period 1993-2001
818 subjects with VBA stroke
Case crossover portion: 4 control periodsrandomly chosen from the year before the stroke
Case control portion: 4 age and sex-matchedcontrols from provincial insurance database
Evidence Linking ManipulationEvidence Linking Manipulationto Stroke?to Stroke?
Case control study
Visiting chiropractor in month before stroke
> 45: OR 0.83 (95% CI: 0.52-1.32)
< 45: OR 3.13 (95% CI: 1.48-6.63)
Evidence Linking ManipulationEvidence Linking Manipulationto Stroke?to Stroke?
However,…
Case control study
Visiting GP in month before stroke
> 45: OR 2.67 (95% CI: 2.25-3.17)
< 45: OR 3.57 (95% CI: 2.17-5.86)
Evidence Linking ManipulationEvidence Linking Manipulationto Stroke?to Stroke?
“… [A similar association betweenchiropractic and GP visits in the monthbefore the stroke event] suggests that
patients with undiagnosed VA dissectionare seeking clinical care for headache andneck pain before having a VBA stroke…”
Cassidy JD, et al. Risk of vertebrobasilar stroke andchiropractic care. Spine 2008;33:S176-S183.
First Relevant QuestionFirst Relevant Question
How do we identify patients at riskfor cervical artery dysfunction?
Second Relevant QuestionSecond Relevant Question
How do we identify patients with cervicalartery dysfunction in progress?
They are not all this easy…They are not all this easy…
Presenting Complaint?Presenting Complaint?
Major presenting complaint of 137 patientswho subsequently had an SMT-inducedvertebrobasilar vascular incident
Presenting ComplaintPresenting Complaint
47.4%: Neck pain and stiffness
19.7%: Neck pain, stiffness, and headache
16.8%: Torticollis
2.2%: Low back pain
2.2%: Abdominal complaint
1.5%: (Kypho) scoliosis
1.5%: Head cold
1.5%: Upper thoracic pain
0.7%: Upper limb numbness
0.7%: Hay fever
Terrett AGJ. Vertebrobasilar stroke following spinal manipulationtherapy. In: Murphy R. Conservative Management of Cervical SpineSyndromes (2000)
What about Risk Factors?What about Risk Factors?Atherosclerosis
Hypertension
Hypercholesterolaemia
Hyperlipidaemia
Hyperhomocysteinaemia
Diabetes mellitus
Genetic clotting disorders
Infections
Smoking
Free radicals
Upper cervical instability
Migraine
Direct vessel trauma
Autosomal polycystic kidneydisease
Iatrogenic causes
Endothelial inflammatorydisease (e.g., temporalarteriitis)
Arteriopathies
Age
Female gender
Thyroid disease
Oral contraceptive use
Direct Vessel Trauma:Direct Vessel Trauma:
Manipulation
Whiplash
Direct Vessel Trauma:Direct Vessel Trauma:WhiplashWhiplash
In a retrospective analysis, Beaudry andSpence attributed 70 of 80 traumaticallyinduced cases of vertebrobasilar ischaemiato motor-vehicle accidents
Beaudry M, Spence JD. Motor vehicle accidents: The most common causeof traumatic vertebrobasilar ischaemia. Can J Neurol Sci 2003;30:320-
325
Whiplash and DizzinessWhiplash and Dizziness
Dizziness, vertigo, and dysequilibrium aresymptoms in 20-58% of individuals that
have sustained a whiplash-type injury of thecervical spine or a closed head injury
Wrisley DM, et al. Cervicogenic dizziness: A review ofdiagnosis and treatment. J Orthop Sports Phys Ther2000;30:755-766
Whiplash and DizzinessWhiplash and Dizziness Damaged peripheral labyrinth or cochlea in 90% and both
in 69% of 227 post-whiplash patients at neurologyevaluation
92% met the diagnostic criteria for inner ear contusion
Of this subgroup, 63% was diagnosed with BPPV, 64%with secondary endolymphatic hydrops, and 21% withunilateral or bilateral perilymphatic fistulae
25% prevalence of BPPV in 273 consecutive patients withrear-end impact whiplash injury without head injury
Grimm RJ. Inner ear injuries in whiplash. J Whiplash Rel Disord 2002:1:65-75;Oostendorp RAB, et al. Dizziness following whiplash injury: A neuro-otological studyin manual therapy practice and therapeutic implication. J Manual Manipulative Ther1999;7:123-130
Not all Dizziness Implies CADNot all Dizziness Implies CAD
Benign Paroxysmal Positional Vertigo
Cervicogenic dizziness
Vertebrobasilar insufficiency
Dizziness type Nystagmus and dizzinesscharacteristics
Associated signs andsymptoms
Cervicogenicdizziness
Positioning-type No latency period Brief duration Fatigable with
repeated motion
Nystagmus Neck pain Suboccipital
headaches Cervical motion
abnormality onexamination
BPPV Positioning-type Short latency: 1-5seconds
Brief duration: <30seconds
Fatigable withrepeated motion
Nystagmus
Cervicalarterydysfunction
Positional-type Long latency: 55+/-18 seconds
Increasingsymptoms and signswith maintainedhead position
Not fatigable withrepeated motion
Ischaemic and(depending on etiology)possibly non-ischaemicsigns and symptoms asdescribed in Table 10
HallpikeHallpike--Dix ManeuverDix Maneuver
Positional nystagmuson this test has beenshown to identifypatients with posteriorSCC BPPV with 78%sensitivity
Specificity as high as88% has been reported
Age: 30Age: 30--45 year old?45 year old?
Gender: FemaleGender: FemalePredisposition?Predisposition?
Terrett (1995) literature review of 185 patientswith severe CSMT complications
Gender known for 180
77 males (42.8%) of whom 13 died (16.9%)
103 females (57.2%) of whom 17 died (16.5%)
Reflects of male-female ration in chiropracticoffice: 40.7-59.3% or 44.8-55.2%?
ArteriopathiesArteriopathies
Marfan syndrome
Ehlers-Danlos syndrome
Fibromuscular dysplasia
Cystic medial necrosis
Osteogenesis imperfecta
Alpha-1-antitrypsin deficiency
Autosomal dominant polycystic kidney disease
Marfan SyndromeMarfan Syndrome
Higher reported incidence of CAD
Typically show signs of impaired skeletal integrityresulting in joint hypermobility
Extremely arched palate with crowded teeth
Long limbs, spider-like fingers: Arachnodactyly
chest abnormalities: Pectus excavatum
Kyphoscoliosis
Sometimes only vascular defects with minimal orno outward clinical manifestations
EhlersEhlers--Danlos SyndromeDanlos Syndrome
Higher reported incidence of CAD
Vascular Type IV variant may play a role infamilial CAD
History of easy bruising
Thin skin with visible veins
Characteristic facial features: Protruding eyes,small chin, thin nose and lips, and sunken cheeks
Martin JJ, et al. Familial cervical artery dissections: Clinical,
morphologic, and genetic studies. Stroke 2006;37:2924-2929
Hypermobility: Beighton ScoreHypermobility: Beighton Score
Hypermobility: Brighton CriteriaHypermobility: Brighton Criteria
Fibromuscular DysplasiaFibromuscular Dysplasia
Rare non-atherosclerotic and non-inflammatory vascular condition
Primarily affects medium-sized arteries, inparticular the ICA and renal arteries
Present in females 3 to 4 times morefrequently than in males
Bilateral in 65% of patients
Fibromuscular DysplasiaFibromuscular Dysplasia
May be related to mechanical stress to the arterialwall, ischaemia within the vessel due todisturbance of the vasa vasorum, or hormonalactivity that negatively affects the muscular wall
Present in up to 23% of patients with ICAdissection
Presenting complaint may vary from TIA toheadache and dizziness
Cystic Medial NecrosisCystic Medial Necrosis
Focal degeneration of the elastic tissue andmuscle of the tunica media, with thedevelopment of mucoid material
Associated with a variety of systemicdisorders
Typically occurs in patients > 40
Male: female ratio = 2:1
Cystic Medial NecrosisCystic Medial Necrosis
Typically affects large arteries, chiefly theaorta
Sometimes associated with the cervicalarteries
Breakdown of collagen, elastin, and smoothmuscle, along with an increase in theartery’s ground substance
Ehlers-Danlos and Marfan syndrome
Osteogenesis ImperfectaOsteogenesis Imperfecta
Bone fragility
Also blue sclerae, diminished hearing,thinness of the skin, and joint hypermobility
Type 1 associated with CAD: Decreased orstructurally defective type I collagenproduced
AlphaAlpha--11--Antitrypsin DeficiencyAntitrypsin Deficiency
• Circulating serine proteinase inhibitor ofproteolytic enzymes that contributes tomaintenance of integrity of connective tissues
• Deficiency provides insufficient protection againsteffect collagenase and elastase and may damagevessel wall
• Genetic systemic disorder with lung and liverdisease
AlphaAlpha--11--Antitrypsin DeficiencyAntitrypsin Deficiency
• 22 consecutive patients with SCAD and 113 controls with non-CADstroke
• Significantly lower levels in CAD (P=0.01)
• OR 17.7 (95% CI: 2.9-105.6) for A1-AT levels < 90 mg/dl
Findings were refuted by a more recent and methodologically soundstudy
Another small study consisting of 12 spontaneous CAD patients found3 cases with a deficiency of alpha-1-antitrypsin
Overall, there is little evidence in support of this relationship
Vila N, et al. Levels of α1-antitrypsin in plasma and risk of spontaneous cervicalartery dissections. Stroke 2003;34:e168-169; Haneline M, Lewkovich GN. Anarrative review of pathophysiological mechanisms associated with cervical
artery dissection. J Can Chiropr Assoc 2007; 51(3):146–157
Autosomal DominantAutosomal DominantPolycystic Kidney DiseasePolycystic Kidney Disease
Common heritable condition: Prevalence rate of 1in 400 to 1 in 1000
Affecting the renal system
May also lead to extra-renal complications,including connective tissues disorders
Haneline M, Lewkovich GN. A narrative review of pathophysiologicalmechanisms associated with cervical artery dissection. J Can Chiropr
Assoc 2007; 51(3):146–157
Cardiovascular Risk FactorsCardiovascular Risk Factors
Hypertension
Tobacco use
Hypercholesterolaemia
Diabetes
Atherosclerosis
HypertensionHypertension
Frequency of tobacco use, hypertension,diabetes, and hypercholesterolaemia
Group of 153 consecutive patients withCAD, a group of patients with ischaemicstroke unrelated to CAD, and a group ofcontrols
HypertensionHypertension
Hypertension was the only one of 4variables significantly associated withCAD, but only in the subgroup of CADpatients who developed cerebral infarction
Overall OR 1.94 (95% CI: 1.01-3.70)
For VA dissection OR 2.69 (95% CI:1.20-6.04)
AtherosclerosisAtherosclerosis
362 cadaver vertebral arteries
Grade 0 (0% occlusion) to grade 5 (75%occlusion) atherosclerosis
Highest incidence of grade ofatherosclerosis: Grade 3
Mainly in atlanto-occipital portion of VA:4.0%
Also in intra-cranial portion of VA: 35.2%
AtherosclerosisAtherosclerosis
Blood flow proportional to fourth power ofdiameter
Population at risk for developing VBI
Mitchell J. Vertebral artery atherosclerosis: A risk factor in the use of
manipulative therapy? Physiother Res Int 2002;7:122-13
HypercholesterolaemiaHypercholesterolaemia
Prospective study on infection as risk factor forCAD
47 consecutive patients with spontaneous CADand 52 with ischemic stroke
Significantly higher hypercholesterolaemia incontrols (42.6%) versus subjects (12.9%)
Guillon B, et al. Infection and the risk of spontaneous cervical artery
dissection. Stroke 2003;34:e79-e81
HypercholesterolaemiaHypercholesterolaemia
72 CAD patients compared with 72 non-CAD stroke control patients
Diabetes, current smoking,hypercholesterolaemia, and oralcontraceptive use not associated with CAD
Pezzini A, et al. History of migraine and the risk of spontaneous cervicalartery dissection. Cephalagia 2005;25:575-580
HypercholesterolaemiaHypercholesterolaemia
So: Hypercholesterolaemia is protective?
Hypercholesterolaemia more frequent insubgroup of CAD patients with ischaemicevents
Arnold M, et al. Vertebral artery dissection: Presenting findings andpredictors of outcome. Stroke 2006;37:2499-2503
Thyroid diseaseThyroid disease
Case-control study involving 58 subjects
Present in 31.0% of CAD patients (9/29),compared with 6.9% of non-CAD stroke patients(2/29) (P=0.041)
Immunologic mechanisms contributing to thevascular damage?
Reports of ICA dissection in patients with Gravesdisease: Effects of thyroid hormones on thesmooth muscle cells and endothelium of thevascular system
Clinical Vignette # 3Clinical Vignette # 3
39-year old male
Felt dizzy and clammy
Consulted osteopath and received tractionmanipulation
Semi-comatose state and vomiting
Died in hospital 19 hours later
Cerebellopontine infarction followingbilateral vertebral artery dissection
InfectionInfection Seasonal variation incidence of CAD: related to
the higher incidence of upper respiratoryinfections during the winter?
31.3% (95% CI: 26.5-36.4) of cohort of 352 CADpatients developed dissection in the winter
Statistically significantly more than in the spring,25.5% (95% CI: 21.1-30.3), the summer 23.5%(95% CI: 19.3-28.3), and the autumn 19.7% (95%CI: 15.7-24.1)
Paciaroni M, et al. Seasonal variability in spontaneous cervical arterydissection. J Neurol Neurosurg Psychiatry 2006;77:677-679
InfectionInfection
• Prospective study on infection as risk factor for CAD
• 47 consecutive patients with spontaneous CAD and 52with ischemic stroke
• Acute infection present within 4 weeks preceding vascularevent more common in SCAD (31.9%) than controlsubjects (13.5%)
• Crude OR 3.0 (95% CI: 1.1-8.2, P= 0.032)
• Adjusted OR 3.1 (95% CI: 1.1-9.2)
Guillon B, et al. Infection and the risk of spontaneous cervical arterydissection. Stroke 2003;34:e79-e81
Oral Contraceptive UseOral Contraceptive Use
One retrospective case-control study(17subjects, 24 controls) investigating CADrisk factors generated statisticallysignificant findings
Current (but not past) use of oralcontraceptives associated with CAD
Oral Contraceptive UseOral Contraceptive Use
Another case-control study that explored CADrisk factors found that 58.3% of CAD cases wereusing oral contraceptives (27 of 47), as comparedwith 40.0% of the controls who had ischemicstroke from another cause (21 of 52): non-significant difference
No consensus
Haneline M, Lewkovich GN. A narrative review of pathophysiologicalmechanisms associated with cervical artery dissection. J Can ChiroprAssoc 2007; 51(3):146–157
Other Risk FactorsOther Risk Factors
Mechanical stress of coughing, sneezing, orvomiting: OR 1.6 (95% CI: 0.67-3.80)
Vascular risk factors OR 0.14 (95% CI: 0.34-0.65)
Current smoking habit OR 0.49 (95% CI: 0.18-1.05)
Triano JJ, Kawchuk G. Current Concepts in Spinal Manipulation andCervical Arterial Incidents (2006)
Systematic Review of RiskSystematic Review of RiskFactors CADFactors CAD
Systematic review risk factors cervicalartery dissection
Two computerized databases, 1966-2005
31 case control studies
Systematic Review of RiskSystematic Review of RiskFactors CADFactors CAD
Aortic root diameter > 34 (mm): OR=14.2(95% CI: 3.2-63.6)
Homocysteine levels (may causeendothelial damage): OR=1.3 (95% CI:1.05-1.52)
Systematic Review of RiskSystematic Review of RiskFactors CADFactors CAD
Migraine: OR=3.6 (95% CI: 1.5-8.6)
Trivial trauma (neck manipulation): OR=3.8 (95%CI: 1.3-11)
Recent infection: OR=1.6 (95% CI: 0.67-3.80)
Most studies major sources of bias
Rubinstein SM, et al. A systematic review of the risk factors for cervical
artery dissection. Stroke 2005;36:1575-1580
So Where Does This LeaveSo Where Does This LeaveUs?Us?
Presenting complaint provides no relevantinformation
Clinically relevant risk factors: Previousmedical history of treatment with cervicalmanual therapy interventions, hypertension,previous infection, and migraine headache
Questionable risk factors: Atherosclerosis,thyroid disease, and arteriopathies…
Physical Examination?Physical Examination?
De KleynDe Kleyn--Nieuwenhuyse TestNieuwenhuyse Test
In 1927, De Kleyn and Nieuwenhuysereported decreased or even absent vertebralartery blood flow based on cadaverperfusion studies in different head and neckpositions
De KleynDe Kleyn--Nieuwenhuyse TestNieuwenhuyse Test
Based on these anatomical observations and theseearly perfusion studies, the sustained extension-rotation and the sustained rotation tests have beenproposed and widely instructed and used as teststo determine the presence of vertebrobasilar arterydysfunction
De Kleyn A, Nieuwenhuyse AC. Schwindelanfälle und Nystagmus beieiner bestimmten Stellung des Kopfes. Acta Otolaryngologica1927;11:155-157
Sustained ExtensionSustained Extension--RotationRotationTest and VATest and VA
Extensively studied with equivocal results
Some authors have reported significantdecreases in VA blood flow, whereas otherstudies found no changes
Case reports have noted false negativeresults
Case series have reported 75-100% falsepositive results
Sustained Rotation Test andSustained Rotation Test andVAVA
Research findings for the sustained cervicalrotation test are equally equivocal
Significant decreases or no effect noted onvertebral artery blood flow or volume
Sustained ExtensionSustained Extension--RotationRotationTest and VATest and VA
Meta-analysis of Doppler studies of VA bloodflow velocity
Effect size: Cohen’s d
VA blood flow velocity compromised more inpatients than asymptomatic subjects, oncontralateral rotation, in sitting more than lying,intra-cranial more than cervical
Mitchell J. Vertebral artery blood flow velocity changes with cervical spine rotation: A meta-analysis ofthe evidence with implications for professional practice. J Manual Manipulative Ther 2009;17:46-57.
Sustained (Extension)Sustained (Extension)Rotation Test and ICARotation Test and ICA
Refshauge noted an increase in right ICAblood flow velocity with sustainedcontralateral rotation in healthy volunteers
Sustained (Extension)Sustained (Extension)Rotation Test and ICARotation Test and ICA
In contrast, Licht et al found no change in peakflow or time-averaged mean flow velocity in theICA during sustained extension-rotation test
Patients nonetheless experienced symptoms(vertigo, visual blurring, nausea, hemicranialparaesthesiae) classically considered a positiveresponse on this test
Licht PB, Christensen HW, Høilund-Carlsen PF. Carotid artery bloodflow during premanipulative testing. J Manipulative Physiol Ther2002;25:568-572.
Sustained (Extension)Sustained (Extension)Rotation Test and ICARotation Test and ICA
Rivett et al reported increase in ICA blood flowvelocity with cervical extension due to narrowingin the ICA?
Decrease in peak systolic and end-diastolic bloodflow velocity in both ICA during sustainedrotation
Found no between-group differences for subjectsthat were positive or negative on this test
Rivett DA, Sharpless KJ, Milburn PD. Effect of premanipulative testson vertebral artery and internal carotid artery blood flow: A pilotstudy. J Manipulative Physiol Ther 1999;22:368-375.
Psychometric DataPsychometric Data
Duplex Doppler ultrasonography
Measured blood flow and vessel diameter
Subjects 1,108 consecutive subjects referred forneurovascular evaluation
136 (12.3%) had unexplained vertebrobasilardistribution symptoms
Extension-rotation position held for at least 10seconds
Sakaguchi M, et al. Mechanical compression of the extracranial vertebral
artery during neck rotation. Neurol 2003;61:845-847
Psychometric DataPsychometric Data
Richter and Reinking calculated diagnosticaccuracy statistics
Comparing signs and symptoms withextension rotation as clinical test and USfindings as reference test
Richter RR, Reinking MF. Evidence in Practice. Phys Ther 2005;85:589-599
Psychometric DataPsychometric Data
Psychometric DataPsychometric Data
Sensitivity 9.3% (95% CI: 4-19.9%)
Specificity 97.8% (95% CI: 96.7-98.5%)
LR+ 4.243 (95% CI: 1.678-10.729)
LR- 0.928 (95% CI: 0.851-1.011)
Interpretation?
Psychometric DataPsychometric Data
12 experimental and 30 control subjects recruitedfrom chiropractic clinics
Experimental group had history of symptomsrelated to head and neck movement and positiveWallenberg test (head and neck extension-rotationfor 30 seconds)
Non-vascular causes excluded by radiography andneurologist examination
Côté P, et al. The validity of the extension-rotation test as a clinicalscreening procedure before neck manipulation: A secondary analysis.J Manipulative Physiol Ther 1996;19:159-164
Psychometric DataPsychometric Data
Extension-rotation test held for 30 seconds
Doppler ultrasound at C3-C5: Systolic peakvelocity to end-diastolic minimum velocity
Positive index test: Vertigo, nausea,tinnitus, lightheadedness, visual problems,numbness of the face or one side of thebody, nystagmus, vomiting, or loss ofconsciousness
Psychometric DataPsychometric Data
Predictive ValidityPredictive Validity
How can positional testing ofhaemodynamics in a still patent vessel beexpected to produce clinically usefulinformation regarding the risk of injury withmanipulative interventions?
Predictive ValidityPredictive Validity
With an already pathologically weakened vesselwall, performing the test itself might put thepatient at greater risk due to the potentialstretching forces exerted
At least in cadaver studies, strain values producedduring the test exceeded those produced withmanipulation
Thiel H, Rix G. Is it time to stop functional pre-manipulation testing of the
cervical spine? Man Ther 2005;10:154-158
Predictive ValidityPredictive Validity
Haldeman et al did a retrospective analysis of 64medicolegal records describing cerebrovascularischaemia after cervical SMT
The clinicians involved described doing thesustained extension-rotation test in 27 cases
None of these patients had adverse responses
Haldeman S, et al. Unpredictability of cerebrovascular ischaemiaassociated with cervical spine manipulation therapy: A review of sixty-
four cases after cervical spine manipulation. Spine 2002;27:49-55
Again, Where Does ThisAgain, Where Does ThisLeave Us?Leave Us?
Presenting complaint
Clinically relevant risk factors
Questionable risk factors
Sustained extension-rotation test would atthe very most only seem relevant whenpositive
Teaching Provocative TestsTeaching Provocative Tests
17/20 member organizations IFOMT teachprovocative tests involving rotation +/-extension
In March 2004, clinic directors of all USchiropractic colleges agreed to abandonteaching provocative tests
Rivett D, Carlesso L. Safe Manipulative Practice in the Cervical Spine (2008)
Clum G. Cervical Spine Adjusting and the Vertebral Artery (2006)
Remember the Two RelevantRemember the Two RelevantQuestions?Questions?
Goals of history and examination
Screen patients at risk for adverse effectwith intervention
Identify patients with cervical arterydysfunction in progress?
FiveFive DDss AAnd Threend Three NNss
Dizziness
Drop attacks
Diplopia (including amaurosis fugax and cornealreflux)
Dysarthria
Dysphagia (including hoarseness and hiccups)
Ataxia of gait
Nausea
Numbness (in ipsilateral face and/or contralateralbody)
Nystagmus
NystagmusNystagmus
Repetitive, back-and-forth, involuntary eyemovements initiated by slow drifts awayfrom the visual target
Pendular nystagmus consists of slowsinusoidal oscillations
Jerk nystagmus is characterized by analternating slow drift and a quick correctivephase
NystagmusNystagmus
Spontaneous nystagmus may imply an acuteperipheral vestibular lesion and may occurin the symptom-free interval in patientswith vestibular migraine
Jerk nystagmus with the quick phaseindicating the unaffected side
NystagmusNystagmus
Purely vertical (upbeat or downbeat) ortorsional spontaneous nystagmus isindicative of a central vestibular lesion
Nystagmus due to a central lesion usuallycannot be suppressed with visual fixation
NystagmusNystagmus
Positional downbeat vertical or skewnystagmus: Posterior fossa lesions (Arnold-Chiari malformation or another compressivelesion at the foramen magnum)
NystagmusNystagmus
Pendular nystagmus occurs most commonlyin patients with multiple sclerosis and brainstem stroke
Cervical Artery DysfunctionCervical Artery Dysfunction
Non-ischaemic signs and symptoms
Ischaemic signs and symptoms
Vertebrobasilar system
Internal carotid artery
NonNon--Ischaemic Signs andIschaemic Signs andSymptoms VASymptoms VA
Ipsilateral posterior neck pain
Ipsilateral occipital headache
Sudden-onset and severe
Described as stabbing, pulsating, aching,“thunderclap”, sharp, or of an unusual character
“A headache unlike any ever experiencedbefore…”
Rarely C5-C6 nerve root impairment due to localneural ischaemia
Ischaemic Signs andIschaemic Signs andSymptoms VASymptoms VA
Five Ds And 3 Ns
Vomiting
Loss of short-term memory
Vagueness
Hypotonia and limb weakness affecting arm or leg
Anhydrosis: lack of facial sweating
Hearing disturbances
Horner syndrome
Ischaemic Signs andIschaemic Signs andSymptoms VASymptoms VA
Malaise
Perioral dysaesthesia
Photophobia
Clumsiness
Agitation
Cranial nerve palsies
Hindbrain stroke: Wallenberg or locked-insyndrome
NonNon--Ischaemic Signs andIschaemic Signs andSymptoms ICASymptoms ICA
Ipsilateral upper and mid-cervical pain
Ipsilateral fronto-temporal or peri-orbitalheadache
Sudden onset, severe, uncommon character
Horner syndrome
Pulsatile tinnitus
Cranial nerve palsies
NonNon--Ischaemic Signs andIschaemic Signs andSymptoms ICASymptoms ICA
Ipsilateral carotid bruit
Neck swelling
Scalp tenderness
Anhydrosis face
Ischaemic Signs andIschaemic Signs andSymptoms ICASymptoms ICA
TIA
Middle cerebral artery distribution stroke
Retinal infarction
Amaurosis fugax: Temporary blindness
Local patchy blurring of vision: Scintillatingscotomata
Weakness extra-ocular muscles
Protrusion eye
Swelling eye or conjunctiva
Horner syndrome
Carotid BruitCarotid Bruit
56% sensitivity and 91% specificity for detectionof a 70-99% carotid stenosis when compared withcolor duplex ultrasound
Implication?
Magyar MT, et al. Carotid artery auscultation: Anachronismor useful screening procedure? Neurol Res 2002;24:705-708
Cranial Nerve PalsiesCranial Nerve Palsies
Relevant to the physical examination are thecranial nerve palsies that may occur with cervicalartery dissection
Dissection of the ICA mainly causes CN IX-XIIdysfunction with the hypoglossal nerve initiallyaffected and then the other three nerves;eventually all cranial nerves except the olfactorycan be affected
Cranial nerve palsies are part of the ischaemicpresentation of a vertebral artery dissection
Cranial Nerve PalsiesCranial Nerve Palsies
Cranial nerve Test L/RI. Olfactory Identify different odors + -II. Optic Test visual fields (Confrontation method) + -III. Oculomotor Upward, downward, and medial gaze + -IV. Trochlear Downward and lateral gaze + -V. Trigeminal Corneal reflex, face sensation, clench teeth + -VI. Abducens Lateral gaze + -VII. Facial Close eyes tight, smile, whistle, puff cheeks + -VIII. Vestibulo-cochlear Hear watch ticking, hearing tests, balance tests + -IX. Glossopharyngeal Gag reflex, ability to swallow + -X. Vagus Gag reflex, ability to swallow, say “Ahhh” + -XI. Accessory Resisted shoulder shrug + -XII. Hypoglossal Tongue protrusion (Observe for deviation) + -
Horner SyndromeHorner Syndrome
Four physical signs: miosis, ptosis,enophthalmos, and anhydrosis
Miosis or inability to dilate a pupil
Paralysis of the dilatator pupillae muscle
Horner SyndromeHorner Syndrome
Incomplete ptosis or droopy upper eyelid
Weakness tarsalis superior muscle
Ptosis can occur due to weakness in the levatorpalpebrae, a voluntary muscle innervated by theoculomotor nerve or as a result of weakness in thesympathetically innervated tarsalis superiormuscle
Ptosis can also occur congenitally, and it canoccur as a familial condition, with increasing age,fatigue, depression, and drowsiness
Horner SyndromeHorner Syndrome
Enophthalmus or deeper-seated eye
Weakness orbitalis muscle
Anhydrosis or decreased sweating
Affects ipsilateral head and shoulders
Syndrome often incomplete
Especially the enophthalmus and the anhydrosisare frequently absent
Miosis is often only noticeable in a darkenvironment when the unaffected pupil dilates andthe affected pupil does not
Horner SyndromeHorner Syndrome
Horner SyndromeHorner Syndrome
Three possible locations for the lesion:
The central neuron runs from the hypothalamus tothe ciliospinal center and is located in the cervicalspinal cord (C8-T2)
This may occur as a result of ischaemic processesaffecting the medulla (i.e., vertebrobasilarischaemia) or as a result of insult to the spinal cord
Horner SyndromeHorner Syndrome
The secondary neurons run from theciliospinal center by way of the nerve rootsC8-T2 to the sympathetic ganglia andthrough these ganglia to the superiorcervical or stellate ganglion
This may occur as a result of, e.g.,syringomyelia or a tumor of the apex of thelung
Horner SyndromeHorner Syndrome
The tertiary neuron runs from the stellateganglion to the dilatator pupillae and thevascular supply to the iris
This may occur due to carotid ischaemia
Clinical implications?
Note: A congenital form of Horner’ssyndrome exists and can be recognized byunequal coloring of both irises
Thunderclap HeadacheThunderclap Headache
Headache: DifferentialHeadache: DifferentialDiagnosisDiagnosis
Cervicogenic headache
Tension-type headache
Migraine headache
Cervicogenic HeadacheCervicogenic Headache
Pain, referred from a source in the neck andperceived in one or more regions of the headand/or face, fulfilling criteria C and D
Clinical, laboratory and/or imaging evidence of adisorder or lesion within the cervical spine orsoft tissues of the neck known to be, or generallyaccepted as, a valid cause of headache
Cervicogenic HeadacheCervicogenic Headache
Evidence that the pain can be attributed to the neckdisorder or lesion based on at least one of thefollowing:
1. Demonstration of clinical signs that implicate asource of pain in the neck
2. Abolition of headache following diagnosticblockade of a cervical structure or its nervesupply using placebo- or other adequate controls
Pain resolves within 3 months after successfultreatment of the causative disorder or lesion
Referral Pattern UpperReferral Pattern UpperTrapezius MuscleTrapezius Muscle
Referral Pattern LevatorReferral Pattern LevatorScapulae MuscleScapulae Muscle
Referral PatternReferral PatternSternocleidomastoid MuscleSternocleidomastoid Muscle
Referral Pattern TemporalisReferral Pattern TemporalisMuscleMuscle
Referral Patterns Splenius CapitisReferral Patterns Splenius Capitis
(Left) and Cervicis (Right) Muscles(Left) and Cervicis (Right) Muscles
Referral Patterns SemispinalisReferral Patterns SemispinalisCervicis (Left) and Capitis (Right)Cervicis (Left) and Capitis (Right)
MusclesMuscles
TensionTension--Type HeadacheType Headache
Hypothesized to be related to myofascial triggerpoints
Prolonged nociceptive input may lead to centralsensitization
Amplification of receptiveness of central pain-signaling neurons to input from low-thresholdmechanoreceptors
Clinically characterized by the presence ofhyperalgesia and/or allodynia
TensionTension--Type HeadacheType Headache
Headache has at least two of the following characteristics:
1. Bilateral location
2. Pressing/tightening (non-pulsating) quality
3. Mild to moderate intensity
4. Not aggravated by routine physical activity such aswalking or climbing stairs
Both of the following:
1. No more than one of photophobia, phonophobia or mildnausea
2. Neither moderate or severe nausea nor vomiting
Not attributed to another disorder
Migraine with AuraMigraine with Aura
At least 2 attacks fulfilling criteria 2-4
Aura consisting of at least one of the following,but no motor weakness:
1. Fully reversible visual symptoms includingpositive features (e.g., flickering lights, spots orlines) and/or negative features (i.e., loss of vision)
2. Fully reversible sensory symptoms includingpositive features (i.e., pins and needles, peri-oralparaesthesiae) and/or negative features (i.e.,numbness)
3. Fully reversible dysphasic speech disturbance
Migraine with AuraMigraine with Aura
At least two of the following:
1. Homonymous visual symptoms and/orunilateral sensory symptoms
2. At least one aura symptom develops graduallyover ≥5 minutes and/or different aura symptomsoccur in succession over ≥5 minutes
3. Each symptom lasts ≥5 and ≤60 minutes
Headache fulfilling criteria Migraine without aurabegins during the aura or follows aura within 60minutes
Not attributed to another disorder
CPR Migraine HeadacheCPR Migraine HeadacheDiagnosisDiagnosis
Five questions:
1. Is it a pulsating headache
2. Does it last between 4 and 72 hourswithout medication?
3. Is it unilateral?
4. Is there nausea
5. Is the headache disabling (disrupting dailyactivities)?
CPR Migraine HeadacheCPR Migraine HeadacheDiagnosisDiagnosis
≥ 4 questions yes: LR+ 24 (95% CI: 1.5-388)
3 questions yes: LR+ 3.5 (95% CI: 1.3-9.2)
1 or 2 questions yes: LR+ 0.41 (95% CI:0.32-0.52)
Mnemonic POUNDing: Pulsating, Durationof 4-72 hours, Unilateral, Nausea, Disabling
Relevance thunderclapRelevance thunderclapheadacheheadache
In 27 cases of non-CSMT VAD this headachepreceded the neurological symptoms:
By less than 1 day in < 30% of cases
By 1-3 days in 15%
By 1-2 weeks in 30%
By > 3 weeks in 25%
Terrett AGJ. Vertebrobasilar stroke following spinal manipulation therapy. In:Murphy R. Conservative Management of Cervical Spine Syndromes (2000)
Risk ManagementRisk Management
Manipulation or mobilization
Type of manipulative technique
Upper versus lower cervical techniques
Mobilization or Manipulation?Mobilization or Manipulation?
Michaeli (1993): Questionnaire sent tomanipulative physiotherapists in SouthAfrica
228,050 procedures
Only minor adverse effects reported formanipulation
29 patients receiving cervical spinalmanipulation reported 52 complications
Mobilization or Manipulation?Mobilization or Manipulation?
However:
58 patients receiving spinal mobilization to thecervical spine reported 129 complications
One mobilization patient suffered a CVA
Implication for risk reduction?
Michaeli A. Reported occurrence and nature of complications followingmanipulative physiotherapy in South Africa. Aust J Physiother1993;39:309-315
Manipulation: Effect ofManipulation: Effect ofTechnique?Technique?
Rotation appears to place the greatest stress onarterial structures, especially in the upper cervicalspine
However, Haldeman et al (2002): review 64medicolegal reports
Strokes noted after any type of manipulation
Including rotation, extension, side bending, non-force, and neutral position manipulation
Haldeman S, et al. Stroke, cervical artery dissection, and cervical spine
manipulation therapy. J Neurol 2002;249:1098-1104
Manipulation: Effect of Level?Manipulation: Effect of Level?
Most reported site of VA damage is at C1-C2
Includes traumatic and spontaneousdissections
Mas JL, et al. Extracranial vertebral artery dissections: A review of 13 cases. Stroke1987;18:1037-1047
Mokri B, et al. Spontaneous dissections of the vertebral arteries. Neurology 1988;38:880-885
Saeed AB, et al. Vertebral artery dissection: Warning symptoms, clinical features, andprognosis in 26 patients. Can J Neurol Sci 2000;27:292-296.
Manipulation: Effect of Level?Manipulation: Effect of Level?
Cervical manipulation definable event withevidence of a mechanical effect
Provided and recorded by third parties unlikeetiologic mechanisms such as shoulder checking,hair washing, etc.
“Not to say less recordable mechanical events areless related to dissection”
Kawchuk GN, et al. The relationship between the spatial distribution of vertebral arterycompromise and exposure to cervical manipulation. J Neurol 2008;255:371-377.
Manipulation: Effect of Level?Manipulation: Effect of Level?
Populations studied
5-year retrospective review yielding a cohort of 25patients with VA dissection not related to majortrauma or CSMT from Foothills Hospital, Calgary,AB
26 of 64 cases reported by Haldeman et al fromretrospective case review article
Diagnostic imaging or reports had to be availableto determine location of VA dissection
Manipulation: Effect of Level?Manipulation: Effect of Level?
V3 segment most commonly dissected
Prevalence ratio (PR) V3 versus V1prevalence in CSMT group = 8.46 (95%CI: 3.53-20.24)
PR V3 versus V1 in non-CSMT group =4.00 (95% CI: 1.43-11.15)
Manipulation: Effect of Level?Manipulation: Effect of Level?
Note: Higher prevalence irrespective of exposureto CSMT
“Demonstrates the impact of everyday movementsand postures [on this mechanically morevulnerable segment]”
Age and gender not found to be significant factors
But: V3 vulnerability augmented by CSMTexposure
Manipulation: Effect of Level?Manipulation: Effect of Level?
However, multiple site lesions alsosignificantly more common in both groups
CSMT: PR = 2.67 (95% CI: 1.98-3.58)
No CSMT: PR = 2.44 (95% CI: 1.81-3.29)
Interpretation?
Manipulation: Effect of Level?Manipulation: Effect of Level?
Report of compression at C6 secondaryto osteophyte arising from superiorfacet C6
Citow JS, Macdonald RL. Posterior decompression of the vertebral arterynarrowed by cervical osteophyte: Case report. Surg Neurol1999;51:495-498.
Emergency Procedures: WhatEmergency Procedures: Whatif the Unthinkable Happens…?if the Unthinkable Happens…?Onset of symptoms indicated in 138 of 185 cases:
69%: during CSMT
3%: within minutes of CSMT
8.5%: within 1 hour of CSMT
8.5%: 1-6 hours post-CSMT
5%: 7-24 hours post-CSMT
6%: >24 hours post-CSMT
Emergency Procedures: WhatEmergency Procedures: Whatif the Unthinkable happens…?if the Unthinkable happens…? Do not re-manipulate the patient’s neck
Observe the patient: Transient signs andsymptoms or cervicogenic proprioceptivedizziness?
Refer the patient: rescue and recoveryposition, do not give the patient anything toeat or drink (dysphagia), note the time, call911
I would like to thank DeborahI would like to thank DeborahCracknell for inviting me to doCracknell for inviting me to do
this presentation for you allthis presentation for you allthis afternoon.this afternoon.
Any questions?Any questions?